The defect is recreated and residual normal landmarks are returned to their normal position. Scar is excised to open the airway. Then, the Subunit Principle4,5 is applied—if a defect encompasses more than 50 percent of a convex nasal subunit (the tip or ala) and will be resurfaced with a flap, residual skin within the subunit is excised to resurface the defect as a subunit, rather than as an incomplete patch.
Because all of the ala and the majority of the tip skin were missing or injured, residual normal skin and scar was excised within the entire tip to resurface the right ala and tip as subunits. Although the defect extended into the inferior dorsum and sidewall, the borders of these relatively flat subunits are indistinct and the subunit principle does not apply. Additional normal tissue within the dorsal and sidewall subunits was not excised.
When a convex subunit is resurfaced in its entirety, uniform subunit skin quality is maintained and the flap's border scars lie in the joins between subunits where their reflected light or cast shadows are relatively camouflaged. More importantly, scar between the flap's raw surface and the underlying recipient bed contracts, drawing the flap's surface above the residual normal adjacent skin. When an entire convex subunit is resurfaced, this inevitable wound contraction is harnessed, in combination with appropriately shaped cartilage grafts, to restore uniform convexity of the tip and ala, rather than producing a pincushion patch. The subunit excision of adjacent normal tissue to permit resurfacing of entire subunits is a useful tool but alone does not create an aesthetic result. The restoration of normal will depend on the replacement of thin matching cover skin, of correct dimension and outline, that blends into the adjacent normal skin and is supported by shaped cartilage grafts. A columellar strut of septal cartilage was fixed between the advanced medial crura to restore tip projection (Fig. 5).
Large, deep nasal defects—those greater than 1.5 cm in diameter, requiring cartilage replacement, full-thickness defects, or those adversely located in the infratip or columella (where local flaps do not reach)—must be repaired with regional flaps. Local flaps are inadequate.
A two-stage nasolabial flap is best suited for complete subunit reconstruction of a superficial alar defect. In this case, it is precluded by the size and depth of the defect, inadequate reach, borderline vascularity, and the risk of severe pincushioning. A forehead flap is a better choice because of its reliability, effectiveness, efficiency, and wide application.
A right paramedian full-thickness forehead flap was designed to resurface the tip and right ala, based on a template, created by combining the left contralateral alar template with the left hemitip template (which is flipped over to design a complete tip subunit). The flap replaces the missing external skin of the tip and right alar subunits in exact dimension and nostril margin outline. The lining deficit is estimated by measuring the defect on the contralateral normal nostril. This second template is drawn as a distal extension of the forehead flap and will be folded for lining (Fig. 6).
In full-thickness defects, the dimension and position of missing lining6 is often unknown until the defect is defined intraoperatively. Once identified, it is relatively easy to create a lining pattern and add an extension to a forehead flap to line unilateral or bilateral defects up to 3 cm or larger. Prelaminated or hingeover flaps are unavailable because of the delay needed to prelaminate the flap or heal cover to lining. Based on the healed margin of defect, hingeover flaps do not permit opening the stenotic nostril, without jeopardizing their blood supply. Intranasal lining flaps are useful but often precluded by previous vascular injury, limited size, and intranasal/patient morbidity (Therapeutic: Level V Evidence).7 They are unavailable, in this case, because of embolic vascular injury to their feeding vessels.
Although useful for salvage, skin graft lining is limited to small defects, “take” unpredictably, contract, and preclude cartilage grafting. Second flaps—such as a turnover nasolabial or facial artery musculomucosal flap—have limited applicability. Microvascular lining flaps are used for very large or composite defects, often with irradiation injury, when all other options are unavailable (Therapeutic: Level IV Evidence).8,9
The cover template was positioned vertically above the ipsilateral frown crease, typically 2 to 3 mm medial to the supratrochlear artery, identified by Doppler examination. The axial vessels of the forehead are oriented vertically and are captured by a vertical flap. An oblique design transects these vessels, creating a less vascular random extension. Although no vessels assessable by means of Doppler imaging were present, in this case, the flap should survive, without a named vessel at its base, because of the rich vascularity of the area.
Although a paramedian flap can be based on either the right or the left brow, lateral defects are most easily resurfaced with an ipsilateral pedicle. The contralateral pedicle is farther away from the defect, necessitating a longer flap that may intrude on the hairline in patients with a short forehead. Midline defects can be resurfaced on either a right or a left pedicle.
The cover template was positioned below the hairline and narrows to a pedicle width of less than 1.3 to 1.5 cm at the brow below. It extends inferiorly through the medial eyebrow. This lowers its pivot point, bringing the flap closer to the recipient site, increasing its reach and limiting needed flap length. The lining template is positioned as a distal extension of the covering flap with a few millimeters of excess skin between the cover and lining flaps to ease its folding. If necessary, the lining extension can carry a few hair follicles. They may be visible as “vibrissae” within the nostril. Because the folded extension lies within the area of routine dog-ear excision, it adds minimally to the overall donor burden.
The forehead consists of skin, subcutaneous fat, frontalis muscle, and a thin layer of areolar tissue that lies over the periosteum. Thus, a forehead flap is thicker than nasal skin and must be thinned. It is perfused by a random cutaneous, myocutaneous, and axial blood supply.
Traditionally, a forehead flap is transferred in two stages. At the first stage, soft tissues are excised distally, eliminating the frontalis and some of the axial vessels within the subcutaneous fat. This is not normally significant, but the larger the defect, the wider the area of thinning, the greater the vascular injury, and the less the flap's ability to tolerate wound closure tension.
The flap is then transposed to resurface the defect. Weeks later, once healed to the inferior inset, the pedicle is divided, the superior aspect of the recipient site is reelevated, and the inset is completed.
Unfortunately, at pedicle division, the inferiormost aesthetic parts of the nose cannot be altered without jeopardizing flap vascularity. A poorly designed or malpositioned cartilage graft cannot be shaved, augmented, or repositioned, and additional grafts cannot be placed. Excessive soft tissue cannot be sculpted. Any imperfection must wait for late revision. Wide reelevation of the flap may jeopardize vascularity and necessitate multiple reoperations to improve imperfections.
The two-stage forehead flap is best suited to resurface small defects. Modest defects within the sidewall or dorsum or an isolated subunit alar reconstruction are best. They require only modest distal thinning and lie within relatively flat areas of the nose, needing limited cartilage grafting.
In contrast, large, deep defects—which require large flaps, extensive cartilage grafts, soft-tissue sculpting, and lining replacement—are more reliably resurfaced with a three-stage full-thickness forehead flap. It contains all soft-tissue layers, has a maximum blood supply during its transfer, and is better able to tolerate wound closure.
One month later (Fig. 7), during an intermediate operation, the flap is, in effect, physiologically delayed. It can be completely reelevated from the entire nasal inset with 2 to 3 mm of subcutaneous fat, to develop uniform, thin, supple covering skin.
The entire underlying recipient bed is exposed. Primary cartilage grafts, previously fixed together only with sutures during stage 1, are now healed together as a sculptable unit. Excess soft tissue and primary cartilage grafts can be modified by direct excision over the entire recipient bed. Delayed primary cartilage grafts can be added. This permits modification and complete contouring of the distal, most aesthetic part of the nose—the tip and ala—at initial flap transfer and during the intermediate operation. The pedicle is divided 1 month later (2 months after flap transfer), allowing further sculpture of the superior aspect of the inset.
This three-stage approach also permits a modification of the traditional method of folding a forehead flap to line a full-thickness defect. Typically, after the two-stage approach, the resulting nostril margins are thick, asymmetric, and unsupported because of an inability to accurately position the nostril rim margin or place cartilage support within the folded flap. The three-stage full-thickness flap eliminates these problems. Although the lining is initially too thick and primary support is precluded (as in the traditional two-stage folded approach), excess bulk can be excised, a complete subunit support positioned, and symmetric nostril borders restored during the intermediate operation.
The full-thickness flap resurfaced the entire tip and ala subunits and the distal extension was folded for lining—each sutured with a single layer of fine suture—to the freshened edges of the defect and short turned-up flaps at the nasal base inset. The right nostril margin was left unsupported. An alar batten was not placed.
Because the inferior pedicle is less than 1.5 cm in width, the forehead defect can be closed above the brow, leaving a 1-cm gap under the hairline to heal secondarily. It is covered with petrolatum-impregnated gauze for 1 week and then lubricated daily with petrolatum ointment until secondary healing is complete in 3 to 6 weeks.
Stage 2: Intermediate Operation
(See Video, Supplemental Digital Content 3, which shows intermediate operation-reelevation of a forehead flap and design of an alar batten, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A691.)
One month later, nasal shape and airway are bulky (Fig. 7). The right nostril margin contains no support. However, the folded lining has healed to residual adjacent normal lining and is no longer dependent on the forehead pedicle for vascularity. Fibrosis does not occur in a full-thickness flap until the frontalis is excised or the subcutaneous layer injured, so the external skin is completely unscarred and supple.
First, subunits and landmarks are marked with ink. The folded nostril margin is incised along the proposed nostril margin, and forehead skin is elevated with 2 to 3 mm of subcutaneous fat, based on the superior pedicle (Fig. 8). Underlying subcutaneous fat and frontalis (doubled in the area of folding) are excised, exposing a complete, thin, healed vascular lining envelope (Fig. 9). Accurately designed delayed primary alar support grafts are easily positioned to establish complete three-dimensional support.
Although the ala normally contains no cartilage, when significant alar skin is missing, a cartilage graft must be placed along the nostril margin to support, shape, and brace the ala. Because the skin of the forehead flap remains soft and supple, cartilage grafts are effective whether placed primarily or in a delayed primary fashion. With complete exposure, cartilage grafts are modified or added during the intermediate operation. (See Video, Supplemental Digital Content 4, which demonstrates delayed primary tip and alar battens and return forehead flap to the recipient site, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A692.)
The forehead foil template, which was preserved and resterilized, is used as a guide to design a delayed primary ear cartilage alar batten of correct dimension and nostril border outline. The graft is sutured to the tip structures medially and buried laterally in a subcutaneous pocket at the nasal base, fixed with a temporary percutaneous suture. Then, 5-0 sutures are passed through the alar batten to catch the superficial raw surface of the lining flap, approximating the lining to the cartilage graft. A tip graft was added for projection (Fig. 10). The same foil pattern is used as a guide to trim excess cover and lining along the nostril margin, establishing symmetry with the opposite normal nostril rim (Fig. 11).
Then, the uniformly thin cover skin flap is returned to the recipient site (Fig. 12). It is sutured with a single layer of fine peripheral sutures, combined with several 5-0 percutaneous quilting sutures to eliminate dead space. The quilting sutures are removed at 48 hours and skin sutures are removed at 5 days.
Stage 3: Pedicle Division
One month later (2 months after transfer), the pedicle is divided (Fig. 13). (See Video, Supplemental Digital Content 5, which demonstrates pedicle division, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A693; and see Video, Supplemental Digital Content 6, which demonstrates recipient inset, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A694.) The proximal aspect is trimmed and the eyebrow is returned within the medial brow, as a small inverted V, where it may be mistaken for a frown line. Distally, the superior aspect of the recipient site is sculpted to define a flat sidewall, alar crease, and convex superior ala contour. The nasal inset is completed. The hypertrophic forehead scar in the area of secondary healing is excised and the upper forehead readvanced, permitting complete primary closure of the donor site (Fig. 14).
Stage 4: Revision
Almost all significant nasal reconstructions require a revision to refine delicate nasal landmarks and establish ideal symmetry. (See Video, Supplemental Digital Content 7, which demonstrates late revision and postoperative results, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A695.) If present, an area of secondary forehead healing can be revised. Because all surgical stages had been discussed with the patient initially, the revision was expected. Four months later, the tip and alar landmarks are imprecise. The nostril is small and its margin bulky (Fig. 15). The flap's border, unexpected fullness at the join of the tip and ala and within the superior ala, and the ideal nostril diameter are marked, based on templates of the contralateral ala and nostril (Fig. 16).
When a distinct alar crease must be restored, it is often useful to make a direct incision at its ideal position, disregarding old scars.10 However, in this more subtle case, it was more appropriate to reelevate the forehead flap thinly over the right tip and ala through the flap's peripheral border. Excess soft tissue was excised to sculpt the expected depression between the tip and alar subunits and the ideal convexity of the superior ala.
The nostril margin was incised, elevating the folded lining thinly, to excise excess subcutaneous fat and scar between the reconstructed lining and the previously placed delayed primary nostril margin cartilage graft. A small sponge bolus was placed within the nostril for 48 hours to temporarily reapproximate the lining against the undersurface of the cartilage graft (Fig. 17).
Postoperatively, the forehead and nasal scars are virtually invisible. The nasal subunits are restored. The reconstructed nostril is smaller but breathing is normal. Scarring within the lip and cheek caused by the initial necrosis awaits further maturation and modification (Fig. 18).
An operative plan must be developed before surgery. Important questions should be answered, including the following:
- What is the surgical goal—healed or restored to normal?
- What is missing? What is the true deficiency?
- Should a preliminary operation be performed before formal nasal reconstruction?
- How does the surgeon determine the correct dimension and outline of missing tissues?
- Where should the nose be positioned and how is that determined?
- Should the wound be altered in site, size, or depth?
- What materials, methods, and stages are required?
- How can tissues be transferred and, importantly, modified to restore each missing anatomical layer with the correct skin quality, border outline, and three-dimensional contour?
A regional unit approach provides principles that determine the timing of repair, staging, choice of materials, and design. The repair of large deep defects with a three-stage full-thickness forehead flap has the following advantages:
- Maximal blood supply at the time of initial transfer and during complete flap reelevation during the intermediate operation.
- Ideal conformable cover and a complete subunit support framework.
- The use of primary and delayed primary cartilage grafts.
- The opportunity to revise imperfections and maximize contour of the distalmost aesthetic parts of the nose before pedicle division.
- A safe and reliable method of folding a forehead flap to restore vascular, thin, and supple lining.
The patient provided written consent for the use of her images.
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